ENS Event | |
|---|---|
05:00 Aug 1, 2013 | |
| Title | Agreement State Report - Wrong Fractional Dose Administered to Patient |
| Event Description | The licensee reported the administration of a 700 cGy fractional dose instead of the 500 cGy prescribed fractional dose to a patient during GYN treatment on 8/1/13. The 700 cGy fraction was prepared for another patient. The isotope involved was Ir-192.
The fraction was the second of a three fraction total dose of 1500 cGy. The final fraction will be adjusted so that the total dose to the patient is 1500 cGy. The prescribing physician had been informed. The patient will be informed of the adjustment prior to administration of the final fraction on 8/8/13. There are no anticipated adverse consequences to the patient. The cause is under investigation and the licensee is still discussing potential corrective actions. A Medical Event may indicate potential problems in a medical facility's use of radioactive materials. It does not necessarily result in harm to the patient. |
| Where | |
|---|---|
| Iowa Health - Des Moines Des Moines, Iowa (NRC Region 3) | |
| License number: | 0310-1-77-HDR |
| Organization: | Iowa Department Of Public Health |
| Reporting | |
| Agreement State | |
| Time - Person (Reporting Time:+104.23 h4.343 days <br />0.62 weeks <br />0.143 months <br />) | |
| Opened: | Leo Wardrobe 13:14 Aug 5, 2013 |
| NRC Officer: | Pete Snyder |
| Last Updated: | Aug 5, 2013 |
| 49237 - NRC Website | |
Iowa Health - Des Moines with Agreement State | |
WEEKMONTHYEARENS 492372013-08-01T05:00:0001 August 2013 05:00:00
[Table view]Agreement State Agreement State Report - Wrong Fractional Dose Administered to Patient ENS 434222007-06-14T15:30:00014 June 2007 15:30:00 Agreement State Agreement State Report - Potential Personnel Overexposure 2013-08-01T05:00:00 | |